Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Nurses' perceptions of aids and obstacles to the provision of optimal end of life care in ICU

Contains fulltext : 172380.pdf (publisher's version ) (Open Access

Development and validation of an instrument for assessing cognitive distortions in patients with end-stage renal disease [Desarrollo y validación de un instrumento para la evaluación de distorsiones cognitivas en pacientes con insuficiencia renal crónica terminal]

Background Psychological disturbances are common in patients with chronic renal failure (CRF). From the cognitive-behavioral theoretical perspective, they may be due largely to specific cognitive distortions (CD) that are likely to be modified by brief interventions. The aim of this study was to develop and validate an instrument for evaluation of specific CD among patients with CRF. Method A questionnaire with an encouraging phrase for each of five categories of CD (catastrophizing, dichotomous thinking, outside self-worth, negative self-labeling, and perfectionism) was developed. This was applied to 21 patients with CRF (11 women and 10 men). Based on the technique of natural semantic networks, a set of responses (defining words) with greater semantic weight to each sentence stimulus (core network) were identified and a pilot instrument was developed. This one was applied along with Becḱs inventories of anxiety and depression among 255 patients with CRF (118 women, 137 men) attended in four different hospitals. Results The pilot questionnaire was composed of 46 items with greater semantic weight between 343 original defining words. Sixteen items were discarded for lack of ability to discriminate (1), low internal reliability (8) and duplicated in more than one factor (7). The final instrument of 30 items had an internal consistency of 0.93 for the total scale and more than 0.75 in all subscales. The five factors correlated positively and significantly with each other and with symptoms of anxiety and depression. Conclusions The instrument that is presented is a valid and reliable measure to assess five CD associated with depression and anxiety in Mexican patients with CRF. It is suggested as a useful tool for the design and evaluation of cognitive behavioral interventions for depression and anxiety among patients with CRF

Development and validation of an instrument for assessing cognitive distortions in patients with end-stage renal disease [Desarrollo y validaci�n de un instrumento para la evaluaci�n de distorsiones cognitivas en pacientes con insuficiencia renal cr�nica terminal]

Background Psychological disturbances are common in patients with chronic renal failure (CRF). From the cognitive-behavioral theoretical perspective, they may be due largely to specific cognitive distortions (CD) that are likely to be modified by brief interventions. The aim of this study was to develop and validate an instrument for evaluation of specific CD among patients with CRF. Method A questionnaire with an encouraging phrase for each of five categories of CD (catastrophizing, dichotomous thinking, outside self-worth, negative self-labeling, and perfectionism) was developed. This was applied to 21 patients with CRF (11 women and 10 men). Based on the technique of natural semantic networks, a set of responses (defining words) with greater semantic weight to each sentence stimulus (core network) were identified and a pilot instrument was developed. This one was applied along with Bec?s inventories of anxiety and depression among 255 patients with CRF (118 women, 137 men) attended in four different hospitals. Results The pilot questionnaire was composed of 46 items with greater semantic weight between 343 original defining words. Sixteen items were discarded for lack of ability to discriminate (1), low internal reliability (8) and duplicated in more than one factor (7). The final instrument of 30 items had an internal consistency of 0.93 for the total scale and more than 0.75 in all subscales. The five factors correlated positively and significantly with each other and with symptoms of anxiety and depression. Conclusions The instrument that is presented is a valid and reliable measure to assess five CD associated with depression and anxiety in Mexican patients with CRF. It is suggested as a useful tool for the design and evaluation of cognitive behavioral interventions for depression and anxiety among patients with CRF

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

Background: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit